1. Infusions & Injections
What You Should Know About Documentation
Carondelet Health Charge Compliance
(816) (816) (816) Stacie Cowell Deb Malone Deb Neece
11/16/2018

2. IV Hydration $300 for the first hour $150 each additional hour
IV Hydration is defined as a pre-packaged fluid and electrolyte solutions. LR
D5 ½ NS w/ 20 meq KCL NS
$300 for the first hour
$150 each additional hour
The prices of what we charge are actually the Nursing Time that we are billing. There are very few services that as an organization Medicare allows us to bill nursing time for, but this is one of those charges. We plan to take full advantage of the opportunity. This amount also is reimbursed to your unit.
11/16/2018

3. IV Infusions $325 for the first hour $167.50 each additional hour
IV Infusions (IVPB) are defined as any medication that has been mixed with a large amount of dilutent, and hung to drip in at a predetermined rate.
Banana Bag
Antibiotics
Other Piggy Backs
$325 for the first hour
$ each additional hour
These types of infusions are anything pharmacy has to mix on it’s own. For instance, if they have to add extra potassium to a fluid, it is no longer hydration, but now an infusion. Start and stop times are required for both, so you don’t have to worry about which is which.
11/16/2018

4. IV Injections
An IV Injection can be defined as any substance not being used as a flush, that is pushed directly into the vein by a nurse through a syringe.
The nurse must actively monitor the IV Push at the time of administration.
If you are not physically pushing the drug in and monitoring it yourself, you must record a stop time. One prime example is protonix. Some may give it push, while others hang it up in a bag. What you do is up to you and your unit’s policies, but if you hang it, you must record a start and stop time.
Pushes do not require stop times. It doesn’t matter if you give it over 1 minute or over 7 minutes, one time is sufficient.
11/16/2018

5. IV Injections (cont) $80 Each Time
If medications are administered separately at different times (e.g., 1015 and 1016) and documented appropriately, then an IVP charge may be charged for each administration.
If medications are documented as given at the same time (e.g., 1015) or are given together in the same syringe, only one IVP charge may be charged.
$80 Each Time
In order for us to charge for each medication administration – the HAVE to be at least one minute apart. For legal reasons, I say follow the administration times in your drug reference. That is what the Charge Compliance team bases their charging process off of.
Also, for legal reasons it is important to document the actual time you gave them. For instance you may have a patient with Solumedrol and Protonix both scheduled for If you document both meds at 0900, essentially you are stating that you mixed those incompatible medications in the same syringe and pushed it directly into a vein.
11/16/2018

6. Other Injections $80 Each Time Subcutaneous – SQ Intramuscular – IM
Lovenox, Neupogen
Intramuscular – IM
Rocephin, Pain Medications, Anti-emetics
Vaccines aren’t listed as they have their own special intervention for documentation purposes. It is important to know however that they still must be documented on the MAR and in Meditech. Follow the policy about vaccines.
$80 Each Time
11/16/2018

7. Documentation
The “start time” is the actual time that the medication or hydration actually started to infuse, not when the IV is started.
The “stop time” is the actual time that the medication or hydration actually
stopped infusing, not when the
IV site was DC’d.
For clarification, you may start a Saline Lock at 1000 but you may not hang the fluids until Your start time would be 1030.
For stop time clarification, the doctor may write to saline lock the IV at 0800 which you do, however the patient is then discharged at The patient has a saline lock from 0800 to Your stop time is The IV is DC’d at 1600.
11/16/2018

8. Documentation Ensure that you have clearly
documented if it was an IV Push (IVP) or IV Piggyback (IVPB).
If ordered IV or PO, ensure you have documented which one you give.
Documentation must prove the infusion / injection was ordered, there is medical necessity, and proof of administration.
A big example of clearly documenting IV Push or IV Piggy Back would be for instance Protonix or Pepcid. There is a difference in how they are charged, so remember to document the actual way you give it.
When the drug is ordered IV or PO, again like with Protonix, if you don’t document that you gave it IV, we can only bill for the $8 pill instead of the $86 bag of medication and the $80 IV charge.
11/16/2018

9. Documentation Nurses must clearly document: the name of the drug
strength
route of administration
appropriate IV site
time given
and appropriate signature
The IV site is required on the MAR because we charge separately for each site. If we don’t have the documentation supporting 2 (or more) IV sites, then we can only charge for one.
Signatures are required, if you don’t sign the MAR, it is not legal documentation.
11/16/2018

10. Documentation Start times and stop times
are required for all IV infusions given. This means the time the bag was hung or the IVPB started and the time it was completed.
Make it standard practice to enter the start and stop times in order to receive appropriate reimbursement.
11/16/2018

11. Documentation
A physician’s order “infuse over 1 hour” is not acceptable as a start or stop time
Documentation that reads “Antibiotic infused over 1 hour” is not acceptable as a start or stop time.
Use of an IV infusion pump is not a substitute for documenting the stop time
Ensure that IV Piggyback (IVPB) and IV Push (IVP) modes of administration are clearly differentiated
It doesn’t matter how fast the medication needs to run in, if you don’t document it, we can’t charge it. Many times, the med must run in slower due to a delicate IV site or burning or other reasons, or faster for some reason. Again, if you don’t document it, we can’t charge it.
11/16/2018

12. You Must Document Start Times When….
Hanging a New Bag
Hanging Medications
Returning From a Procedure
Changing the Rate
Restarting After a Delay
Every time you change the bag, you have to document that you did it.
Every time you put up a piggy back, document that you did it.
When the patient comes to you from ER, another floor, surgery, CT, whatever, be sure and document that the patient had fluids or IVPB running or not.
When you change the rate, be sure and document the time you did that. We currently don’t charge for anything below 70ml/hr or TKO rates but we are looking at changing that policy.
When the patient pulls out the IV, and you restart one, be sure you document the start time of the fluids. It doesn’t matter if it was 10 hours between stop and start just be sure and document it.
The biggest problem that Charge Compliance sees is that the prescribed rate and the amount of time the IV ran don’t match. No body has documented an exception, such as stopped for shower or whatever, and the time is over the prescribed time. We can’t charge any of that time. For instance the physician orders NS at 75/hr. It actually runs from 0900 to This is a total of 17 hours. It should have only run for 13 hours. We have now lost $2550 because of it.
11/16/2018

13. You Must Document Stop Times When…
Removing an Old Bag
When the Patient Leaves for a Procedure
Delay in Therapy
Changing the Rate
When Discontinuing the Medication
When Saline Locking the IV
Every time you change the bag, you have to document that you did it.
Every time you stop a piggy back or switch back to fluids, document that you did it.
When the patient leaves your unit for surgery, CT or whatever, be sure and document that the patient had fluids or IVPB running or not.
When you change the rate, be sure and document the time you did that. We currently don’t charge for anything below 70ml/hr or TKO rates but we are looking at changing that policy.
When the patient pulls out the IV, and you restart one, be sure you document the time the patient pulled it out, this is your stop time.
The biggest problem that Charge Compliance sees is that the prescribed rate and the amount of time the IV ran don’t match. No body has documented an exception, such as stopped for shower or whatever, and the time is over the prescribed time. We can’t charge any of that time. For instance the physician orders NS at 75/hr. It actually runs from 0900 to This is a total of 17 hours. It should have only run for 13 hours. We have now lost $2550 because of it.
11/16/2018

14. Why Document?
It is required in order to be compliant with Medicare rules and regulations.
More MONEY for the hospital and your unit.
MONEY = Benefits = Happy Nurses =
11/16/2018

15. Money Matters Captured Charges Monthly Averages St. Mary’s $98,842
St. Joseph
$219,225
Total Monthly Average: $318,067
Total Annual Average: $3,816,804
11/16/2018

16. Money Matters Average Monthly Lost Charges Total: $75,221
St. Mary’s: $24,361
St. Joseph: $50,860
Total: $75,221
Total Average Annual Loss
$902,652
11/16/2018

17. Money Matters Potential Earnings Total Annually: $4,719,456 St. Mary’s
Monthly: $123,203
Annually: $1,478,436
St. Joseph
Monthly: $270,085
Annually: $3,241,020
Total Annually: $4,719,456
11/16/2018

18. Things to Remember Is there a written order?
Nurses must clearly document:
the name of the drug
strength
route of administration
appropriate IV site (if more than 1 is present)
time given
and appropriate signature
Document the stop time
If giving two different medications, in separate syringes, we may not be able to charge unless they are documented at least 1 minute apart or given through more than 1 documented IV site.
11/16/2018

19. Nurses Need to Remember (cont)
Patients receiving a blood transfusion:
The blood transfusion is not an infusion
If the patient is given an additional Infusion / Injection, we can charge for it as long as the documentation is correct
It is required that we have start and stop times for the blood as well.
Blood Transfusions are billable services.
Documentation of Normal Saline is required.
11/16/2018

20. Questions Where can I document? What if the IV goes bad?
Do I have to document on all patients or just the ones with Medicare?
What is the standard TKO rate?
Can I document ahead of time?
What are the legal implications of not documenting?
Where: MAR is the best place. You can document in nurses notes as Charge compliance looks there too.
What if it goes bad? Be sure and document that! The best place is the MAR but NN are acceptable.
Medicare and Joint Commission require that we treat all patients the same regardless of their insurance or lack there of. Therefore, we must document on all patients.
Standard TKO is 21ml/hr per Carondelet policy. You can find that on CNET
Do not document ahead of time. It is not legal and is not chargeable. Medicare will fine us $5000 each time they find out that we charged for this and they take back the money that they already paid.
Remember – if it wasn’t documented, it wasn’t done. Lawyers are now looking for the start and stop times on charts to be sure you monitored that drug and patient.
11/16/2018

21. Thank You!!!
This information is complex and will take some time to absorb.
If you have any questions please feel free to contact any of the Charge Compliance Staff
Stacie (816)
Deb (816)
Deb (816)
Thank you for your time and attention.
11/16/2018